The Dilemma in the Management of Gastrointestinal Bleeding During the COVID-19 Pandemic

Dear Editors:

We have read with great interest the article entitled “Effect of the COVID-19 Pandemic on Outcomes for Patients Admitted with Gastrointestinal Bleeding in New York City” by Dr. Kim and colleagues.¹ Their study reviewed 211 patients admitted with gastrointestinal (GI) bleeding and examined the effect of the Coronavirus Disease 2019 (COVID-19) pandemic in terms of hospital length of stay, differences in blood product transfusion requirement, and rate of endoscopy performed during hospitalization. Results showed that patients admitted with GI bleeding presented with significantly lower hemoglobin (P = .0188) and had increased length of hospital stay (adjusted odds ratio 2.46, 95% confidence interval 1.13–5.34, P = .023). Admitted patients were also significantly associated with receiving at least 1 blood transfusion (adjusted odds ratio 2.86; 95% CI, 1.25–6.55; P = .013). Their analysis showed several implications on patients with GI bleeding due to the massive reorganization to hospital operations during the pandemic. The patients’ reluctance to present to the hospital could have resulted in lower hemoglobin rates. The higher odds of transfusion, longer hospital stay, and lower odds of undergoing endoscopy are likely due to the prioritization of conservative medical management and higher thresholds to perform aerosol-generating procedures. Although we recognize that changes in the hospital operations are significant during the pandemic, we aim to highlight the quality of GI bleeding management being given to the patients that could result in these clinical outcomes. The threshold for doing endoscopy in patients with GI bleeding is also important.

The COVID-19 pandemic has brought about dilemmas in the management of patients with GI bleeding. Although endoscopy can conveniently serve both as a diagnostic and therapeutic tool, the risk of performing the procedure and transmitting the virus may outweigh the benefit in patients with COVID-19. This is true for all endoscopic procedures, hence the markedly limited cases done in endoscopy centers worldwide. Apparently, acute GI bleeding is considered an emergent procedure in the guidelines of different GI and endoscopy societies, hence the dilemma if it needs to be done on a case-by-case basis.²

In general, patients admitted with acute upper GI bleeding should undergo early endoscopy within 24 hours of presentation.³ However, by practice, the priority has still been given on conservative management for patients presenting with GI bleeding. Patients are started on intravenous fluids and proton pump inhibitors. Octreotide infusions are given to patients with suspected or known liver disease while the coagulopathies are corrected. Patients are usually put to nothing per orem and blood transfusion is facilitated as necessary. With these measures, the clinical condition of patients and their hemoglobin levels are frequently assessed. Unfortunately, no specific guideline exists in the treatment of GI bleeding during the pandemic, but by practice, the basic principles of resuscitation and optimizing medical management are observed.⁴ In addition, no concrete guideline has set any threshold for doing the endoscopy in patients presenting with GI bleeding, but it is generally recommended if a patient does not respond to conservative management within 24 hours. However, this threshold can be arbitrary based on emerging experience.

The timing of endoscopy is controversial, as the available evidence varies on pre-pandemic studies. Although most studies favor early endoscopy, there are some that have described on poorer outcomes. A recent study by Lau et al⁵ showed that delaying endoscopy for 24 hours does not affect 30-day mortality compared with doing earlier endoscopy.⁵ Similarly, a case series by Cavaliere et al⁶ has shown that 6 patients with COVID-19 responded to conservative management and did not require an endoscopic procedure during their clinical course.⁶ Given this dilemma in the endoscopic management of GI bleeding, aside from clinical judgment, we think that decisions could be better made using prognostic tools such as the Glasgow-Blatchford score for the pre-endoscopic risk stratification of patients.⁷

Unfortunately, COVID-19 will be with us for a long time and it will continue to have its deleterious effects on GI bleeding management. There will definitely be cases of GI bleeding in the clinics, but to avoid unnecessary risks of viral exposure on early endoscopy, we suggest going back to the basic principles of optimizing conservative management up to 24 hours. Exceptions to this are cases of severe bleeding in which clinical judgment dictates a more aggressive management or if the patient is at high risk of further bleeding or death based on risk stratification. With the latter, we suggest on future studies regarding the use of these tools in the context of the pandemic, as it may be the triaging model we are missing in this dilemma.